Reconstruction of congenital rectovestibular fistula in an adult. Case report.

Anorectal malformations are common congenital anomalies but diagnosis and treatment in adulthood are quite rare. Treatment during adulthood may be challenging due to anatomic and physiologic changes. Posterior sagittal anorectoplasty may provide good cosmetic and functional results even in adult patients. KEY WORDS: Congenital malformations, Rectovaginal fistula, Rectovestibular fistula.

Can omentin-1 be a prognostic marker in surgical intensive care patients?

Background/aim: A member of the adipokine family, omentin-1 is selectively secreted from visceral fat tissue and the omentum. It has been shown that omentin-1 is involved in the pathogenesis of certain diseases and can be used as a prognostic marker. This study first investigated the prognostic significance of omentin-1 in surgical intensive care patients. In addition, the relationship between omentin-1 and laboratory and clinical parameters commonly used in intensive care units (ICUs) was evaluated. Materials and methods: One hundred and fifty-four patients hospitalized in the surgical ICU were included in the study. Blood samples for omentin-1 were collected from the patients displaying clinical condition changes. Changes in omentin-1 levels were observed during the hospital stay of the patients. A total of 423 blood samples were evaluated. Omentin-1 levels were compared to the laboratory parameters routinely monitored in the ICU and the prognostic significance of omentin-1 for surgical intensive care patients was investigated. Results: The median APACHE II score of all patients was (median-IQR, 8.0­6.0 ng/mL). Omentin-1 levels of the alive patients in the ICU (median-IQR, 339.04­407.68 ng/mL) were significantly higher compared to dead patients (median-IQR, 166.40­363.60 ng/mL). Omentin-1 levels were higher in nonsepsis patients compared to the levels of the patients in sepsis and septic shock (p < 0.001). Omentin-1 values were negatively correlated with the C-reactive protein and procalcitonin levels, body temperature, and the SOFA (sequential organ failure assessment score) scores and they were positively correlated with albumin, prealbumin, and glucose levels. Conclusion: Omentin-1 may play a role in the complex constructs of inflammation and metabolic events in intensive care patients. Reduced omentin-1 levels in surgical intensive care patients were associated with poor prognosis and increased mortality.

Air leak syndrome after endoscopic retrograde cholangiopancreatography: a rare and fatal complication.

Endoscopic retrograde cholangiopancreatography (ERCP) is a state of the art diagnostic and therapeutic procedure for various pancreatic and biliary problems. In spite of the well-established safety of the procedure, there is still a risk of complications such as pancreatitis, cholangitis, bleeding and perforation. Air leak syndrome has rarely been reported in association with ERCP and the optimal management of this serious condition can be difficult to establish. Our group successfully managed a case of air leak syndrome following ERCP which was caused by a 3cm Stapfer type I perforation in the posterolateral aspect of the second part of the duodenum and was repaired surgically. Hereby, we describe the presentation and subsequent therapeutic approach.

Lessons learned from the first quadruple extremity transplantation in the world.

BACKGROUND: Limb transplantation is emerging as a promising area of surgery and is an indispensable alternative for prosthetic rehabilitation of amputees, the severity of which is increasing because of combat-related injuries. Successful unilateral and bilateral limb transplantations have already been performed before this operation. METHODS: We performed the first ever quadruple limb transplantation in February 2012. The limbs procured from a 40-year-old man heart-beating donor were transplanted to a 27-year-old male patient who was a quadruple amputee for the last 14 years because of an electrical injury. RESULTS: To shorten the ischemic period to a minimum, 3 separate microsurgery teams worked simultaneously. All extremities were reperfused within 8 hours of procurement, and the operation lasted for 12 hours. Metabolic load was managed by hemodialysis. One hour after the completion of the operation, cardiac arrest developed, resuscitation of which necessitated median sternotomy and temporary partial cardiopulmonary support. Despite the removal of the transplanted limbs and all efforts including continuous hemodialysis, plasmapheresis, and extracorporeal membrane oxygenation, the patient died on the fourth day after transplantation in a clinical condition of severe systemic inflammation. CONCLUSIONS: The problems we faced were difficulty of vascular access for invasive monitoring and fluid replacement, and the severe systemic inflammation effects of which could not be dealt with, despite aggressive supportive treatment. We hope that our experience will enlighten the surgeons who are willing to extend the limits of limb transplantation and serve the success of future operations.

The effect of problem-based learning with cooperative-learning strategies in surgery clerkships.

BACKGROUND: Cooperative learning is used often as part of the problem-based learning (PBL) process. But PBL does not demand that students work together until all individuals master the material or share the rewards for their work together. OBJECTIVE: A cooperative learning and assessment structure was introduced in a PBL course in 10-week surgery clerkship, and the difference was evaluated between this method and conventional PBL in an acute abdominal pain module. METHODS: An experimental design was used. RESULTS: No significant differences in achievement were found between the study and control group. Both the study and control group students who scored low on the pretest made the greatest gains at the end of the education. Students in the cooperative learning group felt that cooperation helped them learn, it was fun to study and expressed satisfaction, but they complained about the amount of time the groups had to work together, difficulties of group work, and noise during the sessions. CONCLUSIONS: This study evaluated the impact of a cooperative learning technique (student team learning [STL]) in PBL and found no differences. The study confirms that a relationship exists between allocated study time and achievement, and student's satisfaction about using this technique.

Scoring systems in the diagnosis of acute appendicitis in the elderly.

BACKGROUND: Although special features of acute appendicitis in the elderly have been described in some studies, no studies evaluating the applicability of appendicitis scores exist in the literature. The aim of this study was to compare Alvarado and Lintula scores in patients older than 65 years of age. METHODS: Patients older than 65 years with appendicitis confirmed by pathology report were matched by year of admission with a group of patients admitted to the emergency department with non-specific abdominal pain. Alvarado and Lintula scores were calculated retrospectively from patient charts. RESULTS: Both scores were observed to operate well in distinguishing between abdominal pain due to appendicitis and non-specific abdominal pain. The Alvarado score was a better predictor compared to the Lintula score. Two parameters (absent, tingling or high-pitched bowel sounds and nausea) had similar prevalence in the control and appendicitis groups. We selected to recalculate the two scores with the exclusion of these two parameters. The two scores performed better but were more similar to each other after the modification. CONCLUSION: Both Alvarado and Lintula scores have a high sensitivity and specificity in the diagnosis of acute appendicitis in the geriatric age group. Their performance improves with exclusion of the two parameters "nausea" and "absent, tingling or high-pitched bowel sounds".

Resuscitation and monitoring in gastrointestinal bleeding.

INTRODUCTION: Gastrointestinal bleeding is a common life-threatening problem, causing significant mortality, costs and resource allocation. Its management requires a dynamic multidisciplinary approach that directs diagnostic and therapeutic priorities appropriately. MATERIALS AND METHODS: Articles published within the past 15 years, related to gastrointestinal bleeding, were reviewed through MEDLINE search, in addition to current guidelines and standards. RESULTS: Decisions of ICU admission and blood transfusion must be individualized based on the extent of bleeding, hemodynamic profile and comorbidities of the patient and the risk of rebleeding. A secure airway may be required to optimize oxygenation and to prevent aspiration. Doses of induction agents must be reduced due to the changes in volume of distribution. Volume replacement is the cornerstone of resuscitation in profuse bleeding, but nontargeted aggressive fluid resuscitation must be avoided to allow clot formation and to prevent increased bleeding. Decision to give blood transfusion must be based on physiologic triggers rather than a fixed level of hemoglobin. Coagulopathy must be corrected and hypothermia avoided. Need for massive transfusion must be recognized as early as possible, and a 1:1:1 ratio of packed red blood cells, fresh frozen plasma and platelets is recommended to prevent dilutional coagulopathy. Tromboelastography can be used to direct hemostatic resuscitation. Transfusion related lung injury (TRALI) is a significant problem with a mortality rate approaching 40%. Prevention of TRALI is important in patients with gastrointestinal bleeding, especially among patients having end-stage liver disease. Preventive strategies include prestorage leukoreduction, use of male-only or never-pregnant donors and avoidance of long storage times. Management of gastrointestinal bleeding requires delicately tailoring resuscitation to patient needs to avoid nonspecific aggressive resuscitation. "Functional hemodynamic monitoring" requires recognition of indications and limitations of hemodynamic measurements. Dynamic indices like systolic pressure variation are more reliable predictors of volume responsiveness. Noninvasive methods of hemodynamic monitoring and cardiac output measurement need further verification in patients with gastrointestinal bleeding. CONCLUSIONS: Management of gastrointestinal bleeding requires a dynamic multidisciplinary approach. The mentioned advances in management of hemorrhagic shock must be considered in resuscitation and monitoring of patients with GI bleeding.

A novel fuzzy logic inference system for decision support in weaning from mechanical ventilation.

Weaning from mechanical ventilation represents one of the most challenging issues in management of critically ill patients. Currently used weaning predictors ignore many important dimensions of weaning outcome and have not been uniformly successful. A fuzzy logic inference system that uses nine variables, and five rule blocks within two layers, has been designed and implemented over mathematical simulations and random clinical scenarios, to compare its behavior and performance in predicting expert opinion with those for rapid shallow breathing index (RSBI), pressure time index and Jabour' weaning index. RSBI has failed to predict expert opinion in 52% of scenarios. Fuzzy logic inference system has shown the best discriminative power (ROC: 0.9288), and RSBI the worst (ROC: 0.6556) in predicting expert opinion. Fuzzy logic provides an approach which can handle multi-attribute decision making, and is a very powerful tool to overcome the weaknesses of currently used weaning predictors.

A gastrointestinal stromal tumor in Meckel diverticulum in an 86-year-old patient.

Meckel diverticulum is the most common congenital anomaly of the gastrointestinal tract. Its prevalence is approximately 2% of the general population. Complications because of Meckel diverticula are rare and almost nil beyond the age of 40 years. This report details the case of an 86-year-old patient with Meckel diverticulum that perforated because of a tumoral lesion at its apex, also known as volvulus of Meckel diverticulum.

A novel fuzzy-logic inference system for predicting trauma-related mortality: emphasis on the impact of response to resuscitation.

INTRODUCTION: Trauma scoring aims for quantification and uniform reporting of trauma-related outcomes. Despite significant advances in trauma scoring, the exact time period at which relevant calculations should be made is not clear. Considering the importance of response to resuscitation, calculation of trauma scores after a period of resuscitation can allow better discrimination of patients who will survive. METHODS: A fuzzy-logic inference system, which is completely based on expert opinion and uses Glasgow Coma Scale (GCS) and systolic blood pressure at arrival to emergency room (ER) and their response to resuscitation as inputs, was developed. Records of the last 150 trauma patients admitted to our surgical intensive care unit (ICU) were used for calculations related to Injury Severity Score (ISS), Revised Trauma Score (RTS), Trauma and Injury Severity Score, and A Severity Characterization of Trauma (ASCOT) systems. Calculation of trauma severity and predicted mortality was performed at different time intervals during resuscitation [at arrival to emergency room (ER), after 1 h of resuscitation, and at ICU admission]. The performance of conventional systems and fuzzy-logic system was compared. RESULTS: Mean ISS was 32.31 ± 14.01. All systems included showed acceptable discriminative power. Among the conventional systems calculated at emergency room admission, ISS was the best performing [receiver operating characteristics (ROC), 0.9033] and RTS was the worst (ROC, 0.8106). Their performances were improved by up to 13% by use of post-resuscitation physiologic variables. Fuzzy-logic inference system performed slightly better (ROC, 0.9247) then the conventional systems calculated at arrival to ER. CONCLUSIONS: Response to resuscitation has significant impact on trauma mortality and must be considered in trauma scoring and mortality prediction. Fuzzy logic provides important opportunities for design of better predictive systems.

[Effects of autologous and homologous blood transfusion on TNF-alpha levels and survival in an intraabdominal infection model]. / Otolog ve homolog kan transfüzyonunun karin içi enfeksiyon modelinde TNF-alfa düzeyleri ve sagkalima etkisi.

BACKGROUND: Autologous blood transfusion is one of the approaches used for prevention of the undesirable immunomodulatory effects of homologous blood transfusion that can cause an increase in cancer recurrence and surgical site infections. On the other hand, the benefits of autologous blood transfusion in that respect are not yet clearly identified. In this experimental study, we investigated the differences in effects of autologous and homologous blood transfusion on tumor necrosis factor (TNF)-alpha levels and survival in an intraabdominal infection model in rats. METHODS: A total of 92 Sprague-Dawley rats were used in the study. Forty-four of those rats were divided into autologous and homologous transfusion groups, and intraabdominal infection was instituted by cecal ligation puncture method on the 7th day after blood transfusion. Blood samples were taken at the 90th minute and at 6-hour intervals after cecal ligation puncture and were used for measurement of TNF-alpha levels by ELISA method. In the remaining 48 rats, survival was investigated within the first week of cecal ligation puncture. RESULTS: Our results revealed significantly depressed TNF-alpha levels in the homologous blood transfusion group, but with respect to survival, no difference was detected between the groups. CONCLUSION: Based on these findings, we concluded that autologous blood transfusion decreases transfusion-related immunomodulation but does not cause a decrease in mortality due to intraabdominal infection.

Preputial skin can be used in all boys with burns requiring grafting.

BACKGROUND: In patients with extensive burns, all unburned areas can be used as donor sites. In male patients with small burns, preputial skin graft may be a good choice in order to avoid donor site problems. METHODS: We retrospectively reviewed 12 patients treated in our burn center from January 1997 to August 2007 with preputial skin grafting. RESULTS: In three patients, preputial skin was the only graft source. In nine patients, other donor sites were also used for split-thickness graft harvesting. In two patients, preputial skin graft was used for periareolar grafting where hyperpigmented healing was preferred. In the rest of the patients, preputial skin graft was used on various parts of the body. Overall success rate for preputial skin graft was 100%. There was no early donor site morbidity. CONCLUSION: Preputial skin is a full-thickness, highly elastic and easy-to-harvest graft that should be considered in all burned male children in whom grafting is needed.

Iliopsoas hemophilic pseudotumor with bowel fistulization.

Haemophiliac pseudotumors are usually observed in the diaphysis of long bones. Pseudotumors due to psoas muscle hematoma are rare and surgical management is difficult. Surgical treatment of these lesions is usually associated with high morbidity and mortality rate. Here, we present a case with iliopsoas haemophiliac pseudotumors with bowel fistulization who underwent three abdominal operations and survived. Based on our experiences in this patient, we recommend to wait for the intraabdominal hematoma and adhesions to resolve and organise, so that the dissection can be kept to a minimum, which decreases the chances of iatrogenic injury and surgical bleeding (Fig. 3, Ref. 15). Full Text (Free, PDF) www.bmj.sk.

Case report: local allergic reaction of bowel wall secondary to ruptured hydatid cyst.

This is a report of a case of local allergic reaction which developed secondary to a ruptured hydatid cyst with a diffuse bowel thickening detected by computed tomography.